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A SURVEY OF RECENT DEVELOPMENTS INBLOOD TRANSFUSION

PART II

By R. DRUMMOND, M.R.C.S.(Eng.), L.R.C.P.(Lond.)Regional Transfusion Officer, Region VIII (Wales)

3. Blood Grouping and Compatibility Tests;The Study of Blood Group Antigens and theirPractical Importance, especially the RhFactor

Considerable advances have been made inblood grouping and serological technique. Bloodgrouping may, on occasion, have to be done bythe clinician. Unfortunately, many transfusionfatalities have resulted from blood grouping errorsmade by inexperienced workers. Nothing is morelamentable than the way these tests have beenlightheartedly undertaken by inexpert workers,with little realization of the hazards involved. InABO grouping tests, highly potent sera with goodavidity are essential. For absolute accuracy, testsmust be carried out on both cells and serum. Inmass grouping tests when some hundreds of bloodsamples are ABO grouped in a day, a usefuladditional control is the checking of all cells testedwith a potent group 0 serum (high titre alpha andbeta) because even the best technician may, onrare occasions, inadvertently omit to put theanti-A and anti-B sera up with some cells undertest. Care must be taken to distinguish group AB,especially A2B and AB from group B blood.Control A, B and 0 cells must be used in the tests.Controls in saline of the various cells under testshould be put up. Clean, fresh blood samples areessential and clotted blood is the ideal (about 3cc.). A detailed discussion of technique is out ofplace here, but any clinician who is likely to have toperform ABO blood grouping or compatibilitytests should first undergo instruction. The onlytechnique upon which, virtually, absolute reliancecan be placed is grouping in tubes. Recording ofresults must always be checked. Blood groupingon tiles or glass slides, especially on cells only, isnot a reliable technique. Compatibility tests by aslide technique are quite unreliable.

In order to ensure even bleeding of donorpanels, and in the interests of safety, only bloodwhich is homologous with that of the recipient inthe ABO (and Rh) system should be transfused.

The transfusion, for instance, of group 0 bloodcontaining potent anti-A or anti-B isoagglutininsor both, to recipients of groups AB, A or B, maybe dangerous since sufficient destruction of therecipient's cells may occur to cause a disastrousreaction. Likewise, neither group A blood withhigh titre anti-B, nor group B blood with hightitre anti-A should be given to AB recipients.The sera of all A, B and 0 donors should betitrated for high titre anti-A or anti-B iso-agglutinins. The blood of those donors whose seracontain potent anti-A or anti-B isoagglutininsshould not be issued to blood banks, but should beused for grouping sera. If a high titre serum be-cause of zoning or haemolysis is not suitable forgrouping serum, the donor blood can be used forstrictly homologous transfusion, e.g., A to A, etc.Although compatibility tests have been greatly

improved in recent years, no absolutely reliabletechnique has, as yet, been devised. Certainly,compatibility tests in which a saline suspension ofdonor's cells are mixed with recipient's serumcannot be completely relied upon. On the otherhand, much greater reliance can be placed uponcompatibility tests carried out in albumin, or,alternatively, using the Coombs' test. This isthe most reliable compatibility test yet devised.The albumin technique may fail sometimes be-cause of zoning of the recipient's serum whichshould, therefore, be diluted once with AB Rh-negative serum. Very rarely, cross-matching ofblood may prove an exceedingly difficult pro-cedure and such cases are really research problemsand should be dealt with by highly trained labora-tory workers. Nevertheless, cases occur in whichthese techniques fail. I have encountered suchcases, but must point out that the Rh factor wasinvolved, and had Rh tests been done beforetransfusion, disastrous reactions would not haveoccurred. The patients were Rh-negative andwere given Rh+ blood, sometimes persistently,despite febrile reactions. Compatibility tests,using saline suspensions of donor cells mixed with

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equal volumes of recipients' sera, failed because ofthe presence of Rh blocking antibody in the re-cipient's sera. Blocking antibody sensitizes cellsbut does not agglutinate them. Other patientswere Rh-negative mothers who had been pregnantwith Rh+ foetuses. Transfusions of these motherswith Rh+ blood resulted in haemolytic reactionsand a few days after transfusion Rh antibodies inthe recipients' svra were readily detected by testsin albumin, or by the Coombs' test. Pre-trans-fusion samples of serum of these mothers wereavailable and compatibility tests, in saline, albumin,or by the Coombs' technique, revealed no in-compatibility with the donor bloods or randomRh+ bloods. However, the transfusion of Rh+blood very rapidly evoked the Rh antibody. Alltraces of Rh antibodies, as can be detected bypresent tests, may disappear from a recipient'sserum, yet a single injection.or transfusion of bloodcontaining the offending Rh antigen, perhapsmany years later, will rapidly evoke the Rhantibody and destruction of the transfused bloodwill then quickly occur, perhaps with disastrousresult. This is the anamnestic reaction. On thisaccount Rh-negative females of childbearing orpre-childbearing age (even if infants) must neverbe transfused or injected with Rh+ blood, for ifsensitization to the Rh factor occurs, and yearslater pregnancy occurs with an Rh+ foetus, theRh agglutinins may be evoked and the foetusharmed. These facts, therefore, should be bornein mind by all concerned with transfusions. Therule of thumb is a simple one, namely, never givean Rh-negative recipient, or a recipient whose Rhgroup is not known, any blood other than Rh-negative blood. If the latter is not available, tidethe patient over the emergency on plasma trans-fusion. Some 15 per cent. of European whites areRh-negative. Since Rh-negative blood is scarce,it is essential that all prospective recipients of trans-fusion should be ABO grouped and Rh typed, sothat blood homologous in the ABO and Rh systemscan be transfused. Out of every ioo donors bled,only five or six will be 0 Rh-negative. There areas many A Rh-negative as 0 Rh-negative persons.Since 0 Rh-negative blood is such a valuable andscarce commodity, it is quite unjustifiable totransfuse it needlessly to recipients of groups AB,A or B, who should receive blood of the same ABOgroup as that to which they belong. Very seldomwill difficulty arise with compatibility tests if careis taken to select blood of the same ABO and Rhgroup as that of the recipient.The discovery of the Rh factor (Landsteiner

and Wiener, 1940) is the greatest advance madesince the discovery of the ABO groups. Its dis-covery has stimulated search for other antigen-antibody systems with the result that such systems

as those of Lewis, Kell, and Lutheran, which are ofclinical importance have been discovered and,doubtless, others exist.

Thl- literature on the Rh factor is now vast, butsome of the developments of importance toclinician and laboratory worker may be mentionedhere. The fallibility of cross-matching tests insaline in the presence of Rh blocking antibody hasbeen mentioned. Blocking antibodies are readilydetected by tests in albumin media (see Mollisonet al., 1948). Agglutination occurs roughly in twostages: (i) the cells acquire agglutinins; (2) thecells then agglutinate. When cells acquireblocking antibody, they become sensitized, butagglutination, i.e. the second stage, does notoccur in saline. Coombs et al. (1945) devised atest for detection of sensitization of red cells. Theiso-antibodies occur in the globulin fraction ofserum. By injecting human serum into rabbits,a rabbit anti-human-globulin serum can beproduced. Sensitized red cells, i.e. cells whichhave absorbed Rh blocking antibody, can be madeto agglutinate by mixing them with suitably pre-pared rabbit anti-human-globulin serum. Thistest, known shortly as the Coombs' test, is a verygreat advance for it is an extremely sensitiveinstrument for detecting sensitization of red cells.It is commonly used in testing the red cells of anew-born infant to find out whether it is afflictedwith haemolytic disease. The Coombs' test is notspecific for the Rh system. For instance, in theacquired form of haemolytic icterus (acholuricjaundice) the test is positive directly on thepatient's washed red cells (Loutit and Mollison,1946), and distinguishes between the congenitaland acquired forms of the disease. It seems that inacquired acholuric jaundice, the patient's red cellsabsorb an immune antibody from his or her ownplasma. The Coombs' test may be of great-use asa form of compatibility test, but, as indicatedabove, it may, on rare occasions, fail.

Space does not permit of a detailed considera-tion of the Rh antigens. In the Fisher classificationthere are six Rh antigens, namely, C, D, E, c, d,and e, and there are subgroups of some of these.The Rh-positive antigens are C, D and E. Theyare positive in the sense that they are the mostprone to provoke formation of immune iso-antibodies if injected into persons whose bloodlacks these antigens. The antigens c, d and every rarely provoke formation of immune iso-antibodies. The allelomorphs of C, D and Eare c, d and e. The common or standard Rhantigen is D, which is present in the blood of85 per cent. of European whites who are definedas Rh+(D+). Rh-negative blood is defined asthat lacking the Rh+ antigens C, D or E. Par-tially Rh+ blood lacks the antigen D, but con-

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tains C or E, and such persons, from the point ofview of receiving standard Rh+(D+) blood, mustbe regarded as Rh-negative. Further, Rh-negative females, and females whose blood containsC or E, but lacks D, may become immunized to theRh factor D through pregnancy with a D+foetus, or in consequence of injection or trans-fusion of D+ blood. It is now known that 50 percent. of D-negative persons, male or female, maybecome Rhesus-immunized by the injection or trans-fusion of D+ blood. Immunization of D-negativemothers to the antigen D in pregnancy seems tooccur in only about 5 per cent. of cases. Im-munization to C is less common, and to E very un-common. Rh+ persons, e.g. CDe/CDe, whoseblood lacks the antigen c may become immunizedto the Rh antigen c, for instance, through trans-fusion with Rh-negative blood, but this is veryrare. Anti-d and anti-e are extremely rare.

Blood which is partially Rh+, i.e. contains theantigens C or E, but lacks D, must not be given toRh-negative persons (cde/cde) lest immunizationto C or E occur. The importance of the Rh anti-gens is that once a person becomes sensitized to aparticular Rh antigen, whether by transfusion orpregnancy, such sensitization will persist for life.Therefore, no person, especially a female, shouldbe transfused with Rh+(D+) blood unless he orshe is Rh+(D+). The risk of immunization withthe other Rh antigens is not so great. No baby,especially a female, should ever be given an in-jection of blood, either intramuscularly or intra-venously, from a random blood donor, least of allits father, lest the donor be Rh+ and the babyRh-negative and Rh-immunization occur. If aninjection of blood is to be given an infant, itsRh group should be ascertained and bloodhomologous in the Rh system procured. Itshould be borne in mind that Rh-negative babies(D-negative) can result from matings of Rh+heterozygous (Dd) persons. The severest forms ofhaemolytic disease are seen in those infants whosemothers have been immunized to the Rh factor bytransfusions or injections of Rh+ blood, perhapsyears previously. To transfuse or inject Rh+blood deliberately into Rh-negative persons, orpersons whose Rh group is not known, whenfacilities for Rh tests are available, is thoroughlybad practice, especially in the case of females ofpre-childbearing or childbearing age. An Rh-negative female (D-negative) who became Rh-immunized in consequence of transfusion or in-jection of Rh+(D+) blood, and who in con-sequence could not produce normal, or evenliving, Rh+(D+) infants, could, no doubt, suefor damages on the grounds of negligence.When a D-negative person not yet immunized

to the Rh factor receives a transfusion of

Rh+(D+) blood, the chance of Rh-immunizationof the recipient occurring is roughly i in 2. IfRh-immunization does not occur, the donor bloodwill survive in vivo normally. However, shouldthe recipient become Rh-immunized, the donor'sred cells will only survive about 50 days in therecipient's circulation and, a few days after theirtotal elimination, Rh antibodies, the titre of whichwill rise for a few days, may be detected in therecipient's serum. This slow, but neverthelessabnormal, destruction of the donor red cells istermed inapparent haemolysis. The evidence ofabnormal destruction of the transfused red cells istheir diminished survival time in vivo. Of course,a subsequent transfusion of D+ blood will havevery different effect for the donor red cells will beabruptly destroyed with, perhaps, disastrous effects.

Antenatal tests on pregnant women should bedone as a routine to find out their Rh group andwhether they are Rhesus-immunized. Such Rhantenatal testing is now done on a colossal scalemainly by the Regional Transfusion Laboratories.It ensures that mothers in need of transfusion willget blood of the correct group (ABO and Rh) andthat infants affected with haemolytic disease willreceive Rh-negative blood transfusion, if it isnecessary.The agglutinins anti-M, -N, -S,* and anti-P are

not of importance as a cause of haemolytic trans-fusion reactions or baemolytic disease of the new-born. Very rarely, anti-A or anti-B may causehaemolytic disease of the foetus. The sub-groups of A are not of clinical importance.

4. Diagnosis and Treatment of HaemolyticTransfusion Reactions, including Incom-patible Transfusion

(a) Diagnosis of Haemolytic ReactionsA haemolytic reaction is, strictly speaking, one

in which destruction of red cells, either of donoror recipient, occurs in the recipient's circulation.However, it is convenient to include here trans-fusions of haemolyzed blood, e.g. blood which hasbeen frozen, overheated or grossly infected, orwhich is long time-expired and has, in con-sequence, become grossly haemolyzed though stillsterile. A haemolytic reaction may be attributableto transfusion of red cells incompatible with therecipient's serum, e.g. in the ABO or Rh system.On the other hand, the transfused red cells maysuffer no harm, but the donor's isoagglutininsmay destroy the recipient's red cells. The re-

* At the time of going to press a report (Cutbush andMollison, Lancet, 1949, 2, I02) of a haemolytic reactionapparently due to anti-S has appeared. An anomalousfeature of this case, however, is the fact that the patientsubsequently also destroyed S-negative blood.

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POST GRADUATE MEDICALIJOURNALinfusion of a patient's own blood, e.g. from theperitoneal cavity, as in ruptured spleen or rupturedectopic gestation, may result in a fatal haemolyticreaction if the blood has been present in theperitoneal cavity for two or three days. The in-vestigation of a transfusion reaction should estab-lish whether or not the transfused red cells havebeen destroyed, whether the transfused blood washaemolyzed when transfused, or whether destruc-tion of the recipient's own red cells occurred. Thecause of the reaction should be established.

It is now possible, especially with the aid ofdifferential agglutination, to state with some pre-cision whether destruction of the transfused redcells or of those of the recipient occurred. Ofcourse simple inquiry may determine the cause ofa reaction, e.g. transfusion of blood which has beenfrozen and therefore haemolyzed. Having estab-lished that blood was normal when transfused,had been properly preserved with glucose, and wasnot time-expired (i.e. aged 2i days or more), it isthen necessary to establish whether incompatibleblood was transfused. The blood groups (ABOand Rh) of donor and recipient should be re-determined. The ideal is a sample of blood fromthe bottle used and pre-and post-transfusionsamples of the recipient's blood. In all trans-fusions, pre-transfusion samples of blood of donorand recipient should be kept for a couple of days incold storage. Further, as a routine, the bottleused in transfusion should be conserved in coldstorage with its contained remnant of blood for24 hours lest investigations prove necessary.Cross-matching tests should be repeated and testsin albumin may be necessary or Coombs' test mayhave to be applied. When incompatible blood inthe ABO system has been given, it may be possibleto find agglutinates of donor red cells in the re-cipient's blood for one to seven days after trans-fusion. The fact that incompatible blood has beentransfused may have to be inferred from laboratoryinvestigations when samples of the donor bloodare not available. This is quite readily done bystudying the in vivo survival of the donor cells andby studying the serum of the recipient for changesin isoagglutinin titre. For instance, Rh antibodiesmay appear in the serum of an Rh-negative re-cipient transfused with Rh+ blood. Again, if Ablood has been given to a B recipient, there will bean initial absorption of the recipient's anti-A iso-agglutinins by the transfused red cells. There-fore, for a day or two after transfusion, the anti-Atitre will be low or no anti-A isoagglutinin may bedetectable. In the latter event a cross-match testwill be fallacious for the donor cells will seem tobe compatible. However, if at intervals aftertransfusion the recipient's serum be titrated, thetitre of the anti-A agglutinins will rise steadily

until about the twentieth day, whereafter it willdecline gradually to its normal pre-transfusionfigure. The same changes will occur when Rh+blood is transfused to a Rhesus-immunized Rh-negative recipient. In a haemolytic reaction, e.g.incompatible transfusion, there may be clinicalevidence of blood destruction such as haemo-globinuria and jaundice, but these do notnecessarily always occur. The colour of the urinemay be deep orange and pigmented casts may bepresent. When haemoglobinuria occurs the urine,if alkaline, will be red due to oxyhaemoglobin, butif acid or neutral its colour will be brown or darkred like port wine, or even black, the dark colourbeing due to methaemoglobin. Glycosuria mayoccur. Masses of haemoglobin debris may bepresent and occasional red cells may be seen.

Differential agglutination may establish normalin vivo survival of the transfused red cells, and ifthere is evidence of haemolysis, e.g. hyperbili-rubinaemia or jaundice shortly after transfusion,the donor's isoagglutinins should be titrated todetermine whether destruction of the recipient'sred cells has occurred. In certain disease pro-cesses, e.g. nocturnal haemoglobinuria, trans-fusion may precipitate severe destruction of therecipient's own red cells, though the donor redcells survive normally (Dacie and Firth, I943).

It must be emphasized here that the proper timeto investigate a transfusion reaction is at the time ofits occurrence, not some days later. The time ofmaximal blood destruction or elimination, eitherof effete red cells, of incompatible blood, or ofhaemolyzed blood, is within one to five hours oftransfusion, though elimination of course com-mences during transfusion. Therefore suchphenomena as haemoglobinaemia, hyperbili-rubinaemia, and agglutinates of donor red cellsmust be sought for an hour or two after trans-fusion. Intravascular destruction of blood is tobe suspected when jaundice or haemoglobinuriacomplicate transfusion. All febrile transfusion re-actions, especially chill or rigor, should be in-vestigated as a routine procedure. A slight febrilereaction may be the sole evidence of an incompati-ble transfusion (Drummond, I944). However, thegreat majority of chills and rigors are due to causesother than destruction or elimination of transfusedblood or, alternatively, destruction of the re-cipient's erythrocytes. When homologous storedblood, because of faulty preservation or mis-handling, or because it is effete, causes a haemo-lytic reaction, little difficulty will occur in estab-lishing the diagnosis, especially as there will beno changes in the isoagglutinin titre of the re-cipient. The occurrence and degree of haemo-globinaemia and hyperbilirubinaemia will dependupon the quantity of blood destroyed in the re-

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cipient's circulation and the rate of its destruction,also upon the quantity of haemolyzed blood trans-fused and the rate of transfusion. For example,the very slow transfusion and destruction of, say,i00 cc. of transfused blood may result in only slighthyperbilirubinaemia and no haemoglobinuria, butif the same quantity is rapidly transfused andabruptly destroyed, both haemoglobinura andmarked hyperbilirubinaemia may occur within anhour or so of transfusion. As a haemolytic re-action may be due to transfusion of haemolyzedblood, a sample of blood from the bottle usedshould be centrifuged and the supernatant fluidexamined for haemolysis. The transfusion ofglucose-citrated blood properly stored for 2Idays is not followed by haemoglobinaemia ormethaemalbuminaemia, though transient hyper-bilirubinaemia will occur since about 2o per cent.of the red cells transfused will be effete (seeMollison, 1943a). Hamilton-Fairley (i940) couldnot find methaemalbumin spectroscopically afterexperimental intravenous injections in man of I4 to25.4 gm. of haemoglobin though Schumm's testwas positive within four to ten hours. On theother hand, methaemalbumin was demonstrated inthe plasma of recipients transfused with amounts ofincompatible blood containing the equivalent of45 to go gm. of haemoglobin. When intravascularhaemolysis is suspected the plasma shouldbe examined spectroscopically for methaemal-bumin.The following procedures should be taken in

the investigation of a transfusion reaction:-(i)If fever, chill, rigor or haemoglobinuria, occur,stop the transfusion at once, re-cap the bottleand conserve remnant of transfusion fluid in coldstorage. (2) One hour after transfusion has ceasedtake for investigation 20 CC. of recipient's bloodwith a dry sterile, or freshly-boiled syringe. It isuseful to have a similar blood sample taken a fewhours later. Never use a syringe sterilized inspirit or antiseptic since haemolysis will result.Put the bulk of the blood into a dry container(preferably a sterile screw-cap bottle) and 2 CC.into a dry oxalated tube. If pre-transfusionsamples of recipient's and donor's bloods areavailable these should be referred for investigation.(3) Examine for haemoglobinuria and casts allurine voided during transfusion and for 48 hoursafterwards. If haemoglobinuria occurs aftertransfusion, but no reaction was noted duringtransfusion, take immediately 20 CC. of recipient'sblood and a catheter or clean sample of urine.Conserve abnormally coloured urine-for investiga-tion. A sample of the donor blood, preferablyfrom the bottle, should be referred for investiga-tion. (4) Do blood culture on recipient if there ispersistent rigor, or a series of rigors; if possible,

take blood culture during rigor. Also take bloodfrom bottle for culture. (5) When jaundice isnoted within a few hours of transfusion and noother symptoms have been noted, take at once20 CC. of the recipient's blood, a catheter or cleansample of urine and conserve remnant (if any) oftransfusion fluid. All samples mentioned aboveshould be referred without delay for investigation.Any pre-transfusion samples of blood of the re-cipient or donor which may be available should, ofcourse, also be referred for investigations. (6)Chart the fluid intake and output for 14 days whena reaction coinplicates transfusion.

(b) Treatment of Haemolytic Reactions- The treatment of haemolytic reactions hasrecently been given renewed study and there isnow a better understanding of the principles in-volved. When there has been gross destruction oftransfused blood or, alternatively, much haemo-lyzed blood has been transfused, renal excretion ofsome, of the haemoglobin may occur and this mayresult in damage to the renal tubules and, inconsequence, their function may be impaired.Suppression of urine may occur and the patientmay pass into, and die of, uraemia. Usually,however, regeneration of the damaged cells of therenal tubules will occur in a few days. With re-generation of the damaged tubules, function willbe restored though some time may elapse beforerenal function is full. Treatment should be con-servative. Alkalinization of the urine before trans-fusion may prevent precipitation of haemoglobinin the renal tubules, but will not remove casts ofpigment precipitate already present. Intravenousinfusion of sodium-citrate immediately a haemo-lytic reaction occurs may be of some benefit. Thesalt-and-water metabolism of the patient requiresmost careful attention. About half of the totalfluid loss of the body is in the urine and, accord-ingly, when there is urinary suppression, the waterintake must be restricted (Black and Stanbury,I948; Muirhead et al., 1948). The fluid intakeshould be restricted to sufficient to balance loss insweat and urine, and should be about il litres perdiem when urinary suppression is complete. Apatient with fever will need more fluid, and loss offluids as in exudates, vomiting, or diarrhoea, shouldbe corrected. Salt intake, too, should be restrictedespecially when no urine is being voided becausethe skin is the only other channel for excretion ofsalt. The patient should therefore be on a salt-free diet when the kidneys fail to pass urine.

Black and Stanbury (I948) recommend that thediet contain 30 gm. of protein per diem. In-cidentally, anaemia and oligaemia, when present,should be corrected by compatible transfusion,since a good circulation of blood through the

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kidneys is obviously desirable. Such heroictreatment as decapsulation of the kidneys is to beavoided, being as likely to kill as cure. Noattempt should be made to "force" the kidneysinto action in the oliguric period as, for instance,by excessive fluid intake (Muirhead et al., 1948).Considerable harm may be done by giving thepatient excessive fluids during the phase of urinarysuppression. The forcing of fluids during thephase of urinary suppression may, in fact, resultin generalized oedema and, in short, water poison-ing. During the phase of suppression of urinethe patient may manifest symptoms of uraemia;the blood urea may or may not rise to a high level.Recovery is heralded by the onset of diuresis whichMuirhead et al. (1948) term the ' salt-losingdiuresis.' During this phase the water lost mustbe replaced lest dehydration occur. The loss ofsalt in the urine, too, must be corrected and in thesalt-losing diuresis phase the body needs mayamount to 20 to 40 gm. salt and 5,ooo to io,ooocc. water daily (Muirhead et al., 1948). Thisphase will last about five days and, thereafter, thepatient can be allowed to regulate his or her ownfluid intake and output. Complete recovery ofrenal function may not occur for several weeks.There remain for consideration those cases of

severe urinary suppression in which recovery isdespaired of, despite correct treatment. In thesecases it may be worth trying blood, peritoneal orintestinal dialysis for removing urea and retainedproducts from the recipient's circulation. For adiscussion of these procedures see Black andStanbury (1948) and Joekes (i949).

5. The Study of Disease with the Aid ofTransfusionKnowledge of the normal in vivo survival of the

transfused erythrocyte has been used successfullyin the study of certain disease processes. Inhaemolytic disease of the foetus, of which thecommonest form is that due to Rhesus-immuniza-tion of the mother, the red cells of the foetusundergo destruction by immune iso-antibodiestransmitted from the mother to the foetus duringpregnancy. Successful treatment of the infantmust therefore involve transfusion of blood whichlacks the antigen, present in the infant's blood,which stimulated the production of the harmfulimmune iso-antibodies in its mother. Nearlyalways the mother is Rh-negative (D-negative)and the affected infant Rh+(D+). When thisis the case, the affected infant must not be trans-fused with D+ blood because such blood willbe rapidly destroyed by the harmful Rh antibodiessubmitted from the mother. Mollison (I943b)has shown that Rh+(D+) blood will be com-pletely eliminated from such an infant's circulation

within ten days. On the other hand, Rh-negativeblood has a normal in vivo survival in the affectedinfant, though in occasional cases some initialdestruction of transfused Rh-negative blood mayoccur. The affected infant will be kept alive bythe transfused Rh-negative blood if given inadequate amount, but the destruction (or elimina-tion) of the infant's own red cells proceeds so thatin some- cases no red cells of the infant will bedetected in its circulating blood and only theRh-negative red cells of the donor will be present.The infant will then appear to be Rh-negative.However, after two or three weeks, differentialagglutination studies will reveal that the infant'sred cells have re-appeared in its circulating blood,indicating that the haemolytic process is coming toan end. As the infant gets older the harmful,immune iso-antibodies transmitted from themother are entirely eliminated and transfusedRh+(D+) blood will then have a normal invivo survival. In haemolytic disease of the foetus,differential agglutination studies have thus clearlydemonstrated that the fundamental pathology,long suspected of being a haemolytic mechanism,is destruction (haemolysis) of the infant's red cellsby harmful immune iso-antibodies transmittedfrom the mother. The red cells of the infant,incidentally, being sensitized by the maternalimmune iso-antibodies, will give a positiveCoombs' test (Coombs et al., I946), and this verysensitive test is extremely useful and very accuratein diagnosing the disease. It is much the mostreliable test yet devised.The congenital and acquired forms of haemo-

lytic icterus (acholuric jaundice) have been studiedwith the aid of transfusion and differentialagglutination (Dacie and Mollison, 1943; Loutitand Mollison, 1946; Mollison, 1947). Thefollowing facts have been established by Loutitand Mollison (1946):-(i) In the congenital orfamilial form of acholuric jaundice the in vivosurvival of transfused red cells is normal, but thered cells of the patients, when transfused to normalrecipients, are eliminated unduly rapidly. (2) Inthe acquired form of acholuric jaundice, transfusedred cells are destroyed abnormally rapidly,whereas the red cells of patients affected withacquired acholuric jaundice survive normally innormal recipients. Further, the Coombs' test ispositive on the washed red cells of patientssuffering from the acquired form of acholuricjaundice, but in the congenital or familial form theCoombs' test on the patient's cells is negative.Even after splenectomy the Coombs' test has beenfound to be positive in the acquired form of thedisease. These facts are important and indicatethat ' there are two different conditions having adifferent aetiology within the syndrome of

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October I949 DRUMMOND: A Survey of Recent Developments in Blood Transfusion 477

acholuric jaundice' .(Loutit and Mollison, 1946).It would seem that in the acquired fornmL of thedisease the patient has an immune antibody whichdestroys not only the patient's red cells, but thoseof transfused blood. In some cases of acquiredacholuric jaundice studied by Mollison (I947), theeffect of splenectomy was beneficial in that therate of elimination of transfused red cells becameless than it was before splenectomy. The factthat in the congenital or familial form of thedisease the Coombs' test on the patient's red cellsis negative would seem to indicate that no antigen-antibody system exists which causes haemolysisof the patient's red cells. The congenital orfamilial form of acholuric jaundice is, therefore,apparently due to an inherent (hereditary) defectof the erythron and, as noted, the red cells ofpatients affected with the congenital or familialform of acholuric jaundice do not have a normal invivo survival in the circulation of normal re-cipients. This suggests that the red cells in thecongenital or familial form of the disease are un-duly susceptible to normal destructive processes.Normal erythrocytes retain their normal fragilityin the circulation of patients suffering from con-genital or familial haemolytic anaemia (Mollison,1947) which suggests that, in congenital orfamilial haemolytic anaemia, the basic abnormalitylies in the erythrocytes. It is clear that thecongenital and acquired forms of acholuricjaundice can be distinguished with the aid oftransfusion and differential agglutination studies,and by the Coombs' test.The red cells of a patient with nocturnal haemo-

globinuria, when transfused to normal subjects,were eliminated more rapidly than normal, i.e.even in a normal environment they underwentdestruction more rapidly than normal (Dacie andMollison, 1949). On the other hand, the redcells of normal persons have a normal in vivosurvival in patients suff ring from nocturnalhaemoglobinuria (Dacie anFirth, 1943; Mollison,1947). Therefore, in this disease, as in familialhaemolytic anaemia, abnormal destruction oftransfused normal erythrocytes does not, ap-parently, occur. These observations make it clearthat there must be some fundamental abnormalityof the patient's red cells in nocturnal haemo-globinuria since they become haemolyzed inhuman serum in vivo and, as is known, in vitro aswell. There is no evidence that the patient's redcells are harmed by some antibody elaborated bythe patient since transfused normal red cells have

a normal in vivo survival in the recipient's circula-tion. Mollison (I947) found that in the acutehaemolytic anaemia associated with chronicmalaria (' black water fever') transfused red cellswere rapidly eliminated during the phase ofhaemoglobinuria, but that thereafter the elimina-tion was within the limits of normality.

All these observations are of interest and indicatethat blood transfusion and its allied tests canprofitably be used in research in certain diseases,especially haemolytic processes. Transfusion, apowerful instrument in the hands of the clinician,may likewise become a useful instrument in thehands of the research worker.

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